In 2016 it was announced mental health and hospital trusts in England would be incentivised to deliver brief interventions for alcohol and smoking as part of the NHS Commissioning for Quality and Innovation (CQUINs). PHE says CQUIN No.9 Preventing Ill Health by Risky Behaviours is ‘an important opportunity to improve patient health across England’ via the opportunity to ‘identify and support inpatients who are increasing or higher risk drinkers and to identify and support inpatients who smoke, and importantly to embed these interventions into routine care for patients.’

PHE have included a set of infographics which demonstrate the case for implementing alcohol IBA including a potential Return on Investment (ROI) of £27 per patient over four years. PHE say if ‘implemented well the CQUIN has the potential to reduce future hospital admissions and reduce the risk of a number of chronic conditions such as heart disease and, stroke and cancer’, but ‘for it to be effective we need all health professionals, commissioners and local authorities to play their part.’

Many local areas will have already been seeking to implement IBA across a range of settings, either via previous locally commissioned CQUINs or other service provider agreements, or perhaps optimistically by simply training staff roles or dissminating ‘scratch-cards’. Other areas may have focused on the embedding digital interventions, IBA across other settings or novel approaches such as IBA direct.

Efficacy Vs Effectiveness?

IBA has been a central component of alcohol prevention strategies in the UK and in other countries, but whilst there may be good evidence from research trials, the extent of effective routine implementation remains questionable. As such, debates over whether the benefits of brief interventions seen in research trials can be translated to busy front-line settings continue. Indeed such questions may be complicated by the difficulties in researching complex behavioural effects across different settings and population groups, and studies that have had more mixed implications such as SIPS.

Certainly then PHE’s recognition of the need to see such a scheme as ‘well implemented’ in order to see the desired effects seems well warranted. Questions over the actual delivery of ‘brief advice’ conversations beyond simply numbers of people screened or given a leaflet are not possible to answer. Indications from patient studies suggest very few risky drinkers recieve brief advice from their GP practices compared to smokers, despite a national requirement for practices to deliver IBA to new registrations or via health checks. As such calls have been made to do more to consider measures of implementation beyond reported numbers including a ‘national centre’ of IBA, similar to the NCSCT which exists for smoking.

Meanwhile PHE and others have continued to produce resources and toolkits for implementing alcohol strategies which may be seen as important in sustaining local efforts to deliver preventative alcohol interventions, whilst some areas have focussed on ‘Making Every Contact Count’ (MECC) approaches. For others the crucial question may be how achievable ambitions to deliver non-urgent preventive interventions are if pressures on front line services continue to mount.

The Ministry of Defence (MoD) have released figures on an initiative to deliver alcohol brief interventions across the armed forces via dental check ups, identifying 61% of military personnel drinking at a risky or harmful levels.

The MoD has previously come under fire over a lack of action to address high levels of alcohol misuse amongst the armed forces. In 2015 Professor Neil Greenberg, lead on military health at the Royal College of Psychiatrists and a former Navy Commander, said an approach based education alone was not effective. Subsequently an MoD alcohol working group was instigated to “review policy and data to identify what more we can do to tackle alcohol misuse in the armed forces”.

Alcohol brief interventions (ABI), often referred to as Identification and Brief Advice (IBA) in England, have been increasingly sought as a strategy to promote behaviour change amongst at-risk drinkers, as advised by NICE and national health bodies. Much debate has been had though over how and where they should be delivered, with question marks over to what extent various national and local efforts may have been successful.

The MoD report highlights Armed Forces personnel are expected to attend a dental inspection between every 6 to 24 months, therefore presenting an opportunity to deliver ABI to the whole workforce. The initiative used AUDIT-C, a 3 item assessment tool utilising the first three questions of the full AUDIT. Scores of 5 or above on the AUDIT-C indicate a level of risk and/or harm, though it is considered less effective at distinguishing different levels of risk or probable dependence in comparison with the full AUDIT.

The MoD sought to offer all personnel with a score of 1+ (any level of drinking) an alcohol advice leaflet, reporting 80% (n = 80,662) as receiving one. Of the 61% personnel who scored 5-12 on the AUDIT-C, 63% (n = 42,074) were given an ‘Alcohol Brief Intervention’ (ABI), though the report states it is ‘not currently possible to measure how many of these ABIs have been delivered’. Indeed a key question for all ABI initiatives has been to what extent the reported interventions have been delivered, particularly in view of time time limitations and other issues such as a lack of training.

For those scoring 10-12 on the AUDIT-C, a total of 2% (n = 2,502), the MOD states personnel should have also been ‘advised on the importance of seeking further advice from their GP or a local alcohol support service’ in addition to the ABI. Overall, higher alcohol risk levels were associated with being young and single, being of more junior rank and being of white ethnicity, with navy personnel indicating the highest AUDIT-C scores.

Will dental ABIs reduce alcohol misuse in the military?

The report states the MoD is undertaking other initiatives to reduce alcohol misuse, including ABI beyond its dental settings. Measuring the specific impacts of such schemes is notably difficult, though having such data on the levels of alcohol misuse may prove useful data for any future evaluation. However as with wider debates over approaches to reduce alcohol misuse, researchers tend to highlight the need for ‘multi-component’ programmes and supply side controls rather than relying on single initiatives to have a sustained impact.

The MoD’s alcohol working group is likely to face many specific challenges in shifting what MPs have described as a heavy drinking culture within the armed forces. The availability of subsidised alcohol, attitudes and expectations of personnel towards alcohol and the many other complex factors influencing health and wellbeing are all likely to play important roles in seeking such changes. Observers may see a committent to ABIs as welcome, but will hope that they are not relied upon as the sole strategy for addressing alcohol misuse in the military services.

The delivery of ABI in Scotland, or ‘Identification and Brief Advice’ (IBA) as often known in England, has been a central component of national alcohol strategy across the UK, though debates over the quality and extent of implementation have been ongoing.The report on the practice and attitudes of General Practitioners is based on interviews across Scotland, which identified facilitators for the effective delivery of ABIs as falling into two key categories; systemic factors and patient-centred factors. These included key issues such as sufficient time, training and effective IT systems. Barriers were also identifiable in terms of structural and individual level issues, with the availability of cheap alcohol and normalisation of heavy drinking perceived as significant issues.

The report on financial incentives reviewed available literature, examined a number of local systems and interviewed stakeholders. Available evidence indicated a limited and mixed picture, but with some indication of potential for incentives to encourage activity. Exploring local systems also presented a diverse picture and a lack of evidence to account for variations found. Stakeholders too presented contrasting views on the role of incentives, including in relation to the truth behind common concerns such as ‘gaming’ systems to generate income rather than ensuring quality intervention delivery. The report identifies a significant evidence gap remains despite the the ambition of Scotland’s ABI programme.

Professor Aisha Holloway, University of Edinburgh, said:

“Delivering Alcohol Brief Interventions (ABIs) is not just about the operational mechanisms associated with the national ABI programme i.e. funding, training and IT systems. It is also about GPs having the time to provide person-centred care to understand the complexities of external social and personal issues that people are facing that can trigger harmful/hazardous consumption.”

Dr Niamh Fitzgerald, Institute for Social Marketing, University of Stirling said:

“Whilst Scotland’s national programme of Alcohol Brief Interventions is amongst the most extensive of any country, it has contributed little in terms of research on how best to incentivise practitioners to talk to patients about alcohol. As Scotland rolls out its new national strategy, there is also an opportunity for Scotland to lead not only in terms of practice, but in developing globally innovative research on how to optimise such conversations to benefit patients.”

Beyond Primary Care settings, efforts to incentivise IBA across hospitals and mental health trusts across the country should be underway as part of the NHS Commissioning for Quality and Innovation (CQUINs) payments framework from 2017-2019. The CQUIN separates alcohol IBA delivery into two equally weighted metrics – firstly screening using a validated tool, and secondly the delivery of alcohol ‘brief advice or referral’, with appropriate data collection for each.

PHE, NICE and other organisations have also encouraged local areas to seek IBA delivery across a range of settings. Last year an ‘IBA commissioning toolkit’ was released, encouraging systematic approaches and highlighting other case studies. Many in the field though will still agree with the authors of the SHAAP reports – important questions still remain over the ‘what, where, and how’ for effective IBA, as well as the very real challenges in implementing it.

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A recent systematic review of alcohol brief interventions looked specifically at whether the ‘setting, practitioner group and content matter?’. Based on data from 52 research trials, the results conclude that alcohol brief interventions ‘play a small but significant role in reducing alcohol consumption’ – but also identifies some differences based on where and by whom.

Perhaps the most significant finding is that IBA delivered by nurses were found to be most effective. This may be seen as promising given the reach of nurses and recognition of the role of IBA in healthcare settings. However the study cannot tell us how much this finding may be as a result of the way in which nurses deliver the intervention versus other factors such as nurses being seen as a credible person to offer alcohol advice.

As such it suggests nurses should be seen as a priority for the delivery of IBA, with efforts needed to address key barriers of time, worry about losing trust of the patient and inadequate training. It also emphasises previous research suggesting ‘a good relationship between the practitioner and the client’ as an important factor.

The findings also suggest the less intensive approach of ‘brief advice’ was found more effective than longer motivational interviewing interventions. However concerns over ‘brief advice’ being interpreted as simply feedback and a leaflet -rather than say 5-10 minutes structured advice – should be noted.

Another key finding was that when comparing settings, universities were found to have the greatest effect size alongside primary care – surprising given the limited level of attention to IBA in universities. Perhaps another unexpected findings was a lack of evidence for IBA in A&E settings. Whilst previous studies have found small effects, the review suggests that the specific time pressures within A&Es, lack of privacy and seriousness of injuries may be significant in hampering its value as a setting.

The authors rightly highlight limitations to the research and caution over drawing firm conclusions about role and settings. However it may be fair to summarise that it strengthens the case for shorter ‘brief advice’ to be delivered by nurses in particular. In addition, further focus on the potential of universities as a setting for delivery may also be an important area for development. Meanwhile the possibly limited benefits of IBA delivery in busy A&E settings may need to be weighed up against the level of effort required.

Results from the 2015 British Social Attitudes (BSA) were recently released, revealing the vast majority of patients felt either fairly (20%) or very comfortable (75%) talking to their doctor about their alcohol consumption.

Just 2% of respondents were either fairly or very uncomfortable doing so, suggesting there is little justification for the commonly perceived barrier that patients may be defensive when offered brief intervention. A further 3% said they did not feel either comfortable or not.

Furthermore over four-fifths (85%) of people say that they “would answer completely honestly”, while 14% say that they would “bend the truth a little”. Whilst the study found people were more likely so say they would answer honestly if they didn’t drink or were lower risk drinkers, 62% of risky drinkers still said they would be truthfull.

Despite such a high percentage of patients being comfortable to discuss their alcohol use, it is important to note that how such questions – and any subsequent ‘advice’ – is carried out is crucial to the effectiveness of brief intervention.

One of the most important things is to ensure patients do not feel they are being judged or picked out individually for alcohol questions. Whilst many practices screen patients at certain points, initiating IBA can be done whenever a spare moment arises.

Patients of course do have the right to decline, and any following conversation should not be pushy or lecturing. Delivering a validated alcohol assessment such as the AUDIT and offering brief feedback on the person’s score appear to be the most important elements – Primary Care roles musn’t think that patients are against this.

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A series of reports are available following the conclusion of a Middlesex University project exploring the delivery of alcohol brief interventions outside of health settings.

A growing effort to deliver alcohol ‘Identification & Brief Advice’ (IBA) in a range of different settings has emerged over the last decade, but the actual level of delivery by front line practitioners remains questionable. The reports appear to confirm many of the suspected reasons why IBA delivery has proven difficult, ranging from individual level perceived barriers to failures to adopt ‘system wide’ approaches.

To those in the field, it may be no surprise that simply ‘parachuting’ in training without recognising and addressing many of the contextual issues at play is insufficient. Despite this, training is likely to be an important component of any efforts to secure delivery, and participants generally value the knowledge and skills gained. Different roles in different settings though report varied barriers and opportunities and so training and all important organisational strategies may need to reflect these nuances.

The main report looks at these through work on influences on behaviour change undertaken by Susan Michie and colleagues at UCL. Whilst the more traditional ‘cycle of change’ is often used to consider a drinker’s motivation to change, Michie’s work demonstrates the importance of considering the wide range of factors that influence practitioner’s behaviour as potential IBA agents. For example training may address a practitioner’s ‘capability’, but may not address key issues of ‘opportunity’ (e.g when is ‘identification’ actually going to be feasible) or ‘motivation’ (perhaps recognition of doing IBA or personal satisfaction).

Other questions addressed in the research include important questions such as whether in fact IBA should be pursued in various non-health settings. A ‘health in all polices’ approach may be sound, and other added benefits such as possible impact on important indicators like re-offending rates or housing status could also be seen. Yet the evidence base proving the effectiveness of IBA in non-health settings is rather sparse.

Wider brief intervention questions are also relevant. Research efforts are being focused on questions of ‘how’ and ‘who’ does IBA work for. As cited in one of the papers Professor Nick Heather, who has been instrumental in the emergence and development of IBA over 3 decades, summarises this as:

“What kind of brief intervention, delivered in what form, by what kind of professional, is most effective in reducing alcohol consumption and/or problems in what kind of excessive drinker, in what kind of setting and circumstances?”

Given that seeking to secure routine IBA delivery even in health settings includes a range of distinct challenges, any help knowing where else and how IBA will be most effective will be particularly welcome.

Indeed it is easy to see why the tool may have been popular as it neatly includes key ‘components’ of FRAMES based brief advice. Having these prompts and visual aids may take pressure off the practitioner to remember the various things that may be useful to discuss, or perhaps better still, use them as prompts for a drinker to identify things relevant to them. For example:

‘Feedback’ – the tool has several sections that may help the drinker understand what their level of risk is and what that means. The ‘risk category’ table gives an indication of what that may look like in terms of units, whilst the population graph (right)is thought helpful to highlight most people actually drink at ‘lower risk’ amounts.

‘Advice’ – practitioners should of course be careful here. Rather than giving direct ‘advice’, generally better to ask “could you think of any benefits if you did decide to cut down?”. The tool suggests some ‘common benefits of cutting down’ which can be useful prompts.

‘Menu’ of options (goals or strategies) – as above, best to ask “would any these strategies listed here be useful if you did decide to cut down?”. Easy to assume what works for you will work for them, but important they ‘own’ their responses as much as possible (Responsibility).

Not forgetting of course ’empathy’ and ‘self-efficacy’ as the final FRAMES elements – not on the tool because these are skills we try and embed throughout brief intervention – and probably at other times we are in contact with people. As such the evidence behind FRAMES as central to IBA is often questioned, but in a general sense it may be considered useful as a guiding framework.

What about the tool itself?

It is of course impossible to build the ‘perfect’ one size fits all tool when people and drinking motivations are so varied and complex. This is why the tool should just be an aid to facilitating person-centred IBA, rather than the focus.

Interestingly, PHE have done away with the old ‘large white wine’ with 3 units on the side. This is a good move as people frequently commented on the drink’s visual appeal. Indeed a ‘priming’ effect has been found in studies and is one of the reason why ‘responsible drinking messages’ with pictures of alcohol are controversial. Weren’t thinking about wanting a drink? Perhaps you are now you’ve seen one!

It’s replacement though is the new ‘One You’ campaign promoting healthier living in general. I’m not quite sure on how I feel about this yet, although I do agree alcohol brief interventions need to be considered as part of wider health behaviour initiatives.

One thing that could still probably do with updating is the unit examples. ‘This is one unit’ contains some rather dubious examples – when was the last time anyone was served a 125 ml glass of wine at only 9% ABV? Certainly far less often than a 250 ml 14% one, registering at a considerable 3.5 units.

However these finer points may not be that important when considering the likely impact. We know ‘identification’ and ‘feedback’ are most likely to be the critical ‘active’ elements of IBA, complimented by conversations that feel helpful and supportive to the drinker. Such resources are probably more important for nudging and helping practitioners to start these valuable conversations.

The research has found many of same challenges focussed around beliefs and attitudes of non-health staff having alcohol conversations, and of course that training alone doesn’t neccessarily result in routine delivery. Crucially, organisations need to buy in to it so that practitioners are supported and recognised for helping people look at their alcohol use, even if its not in their job description.

There are also many other aspects to consider, not least that people who attend IBA training are given a chance to contemplate their own drinking, or develop skills that may be beneficial in other ways – for example to talk about other health behaviours or things that may need an empathetic approach.

I’ll be on the panel to discuss some of these points and while I won’t be pretending that training is all we need, I will most likely highlight that without it, good quality IBA is unlikely to happen anywhere. And whilst wider alcohol policy is arguably rather weak, IBA is something we shouldn’t give up on.